Running head: ADOLESCENT SEXUAL EDUCATION 1

Safe Sex Education Versus No Education: Integrative Review of the Literature

Kirsten Poole

Bon Secours Memorial College of Nursing

NUR 4122

Dr. Christine Turner

November 1, 2017

I pledge the honor code.

ADOLESCENT SEXUAL EDUCATION 2

Abstract

Purpose: This integrative review aims to determine best practice in prevention of sexually

transmitted infections (STI) and pregnancy in adolescents, as well as provide strategies for

nurses in incorporate the findings into their practice.

Problem: Adolescents remain at high risk for STIs and unwanted pregnancies. The writer seeks

to determine if this is a result of a flawed program of sexual education being delivered to teens.

Method: PubMed databases were searched using the terms “safe sex education”, “adolescent”,

“sexually transmitted infection”, and “no education”. Studies were limited to the years 2013-

2017, and only selected if they were peer-reviewed and written in English.

Findings: The research suggests that over 60% of adolescents initiate sex by the age of 16,

increasing the risk for STIs and unplanned pregnancy. The literature supports that abstinence-

only education is ineffective, while safe-sex education reduces the incidence of risk-taking

behaviors. The articles dictate that open dialogue between teens and healthcare professionals is

necessary in order to promote safe practice.

Limitations: The writer’s limitations include inexperience in research and limited access to free

full-text articles. Delimitations include the writer’s constraint to only 5 articles.

Future research: While this integrative review adds to the topic of adolescent sexual health,

further research is needed on how to incorporate this finding into the clinical setting.
Running head: ADOLESCENT SEXUAL EDUCATION 3

Safe Sex Education Versus Abstinence-only Education

With over 20 million new cases a year, sexually transmitted infections (STI) are

becoming an epidemic (Manlove, Fish, & Moore, 2015; Vasilenko, Kugler & Rice, 2016).

Coupling this statistic with the report that 50% of these cases occur in young men and women

between the ages of fifteen and twenty-four, the question is raised, is preventative action

necessary in order to eradicate this problem in adolescents? In addition to alarming rates of STIs

in youths, the issue of teen pregnancy also persists, with 27 in every 1,000 births in the U.S. are

to adolescents ages 15-19 (Manlove, Fish, & Moore, 2015) This paper aims to determine best

nursing practice in facilitating healthy sexual development in adolescents by identifying an

answer to the PICOT question: is safe-sex education more effective than abstinence-only

education in reducing STI and pregnancy rates?

Design & Search Methods

An integrative review containing five research articles was conducted. The database

utilized for the search was PubMed. Key terms used in the searches were “safe sex education”,

“abstinence only education”, “adolescent”, “sexually transmitted infection”, and “no education”,

yielding 1024 results. This search was limited to a five year time frame, starting in 2013 and

ending in 2017.

Additionally, eligible articles needed to have been peer reviewed and published in a

recognized research journal. Under these parameters, five articles were selected, four

quantitative, and one qualitative. The chosen literature assisted the writer in answering her

PICOT question.

Findings & Results

ADOLESCENT SEXUAL EDUCATION 4

Finer & Philbin (2013) analyzed public data in order to determine age of sexual initiation

and contraceptive use in adolescents, specifically looking at younger teens. In addition, they also

sought to determine pregnancy rates in adolescents. The authors used Results from National

Survey of Family Growth (NSFG) and analyzed them through event history analysis to

determine at what age sex was initiated and correlate this with contraceptive use. Pregnancy rates

were determined by obtaining data from the National Center for Health Statistics. Major

variables of the study included: age at first heterosexual vaginal intercourse; age which use of

contraception (defined as barrier methods, withdrawal, hormonal, and/or periodic abstinence)

was initiated; instances of pregnancy; and pregnancy outcomes, including abortion, adoption,

demise, and assumption of the role of parent.

The authors (Finer & Philbin, 2013) concluded that less than one percent of adolescents

had sexual intercourse by the age of 12, and only two percent by 13. While the study is aimed at

finding statistics about younger teens, Finer & Philbin included rates of sexual initiation for all

teens, with nineteen percent of 15 year-olds having had sex, and thirty-two percent of

adolescents by the age of 16. The study also determined that eighty-two percent of 16 year-olds

used contraceptive methods at their first intercourse, and by one year of their sexual lifespan,

ninety-five percent of the sample used some form of contraception.

Finer & Philbin (2013) limited their research on pregnancy to the year 2008. In this year,

there existed a correlation between and increase in age and an increase in occurrence of

pregnancy. In 13 year-olds, the number of pregnancies was 2,300, whereas in 14 year-olds the

number jumped to 10,200. By 17 years-old, the number of pregnancies was 134,500. Across the

board, in all ages, the number of live births in this sample was almost double the number of

abortions.
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Another study included in the review, Vasilenko, Kugler, & Rice (2016), also analyzed

age of sexual initiation as a variable in determining the risk for STIs and depression across the

lifespan. The researchers collected their data from four waves of the National Longitudinal Study

of Adolescent to Adult Health (Add Health) and used the TVEM model for statistical analysis of

their findings. Major variables examined included timing of first intercourse, lifetime and past-

year incidence of STIs, lifetime and past-week incidence of depression, and ethnicity. A

pertinent finding from the study was that sexual initiation before 16 years old increased lifetime

risk of STIs, contrasted with data indicating initiation after 18 years old decreased this risk.

In the United Kingdom, Pound, et. al. (2017) researched best methods of implementing

mandatory sex and relationship education (SRE) to adolescents in schools. Authors conducted a

quantitative synthesis of information from 5 different studies that they had previously conducted.

Methodology included: telephone interviews with health authorities to determine their opinions

of best practice; a synthesis of 48 studies that looked at school-based sexual education practices;

a qualitative case study regarding factors that make education acceptable to students, parents,

and educators; data from a national survey about sex was analyzed for sexual attitudes and

practices in ages 16-24; and a review of up-to-date systematic reviews and meta-analyses of the

literature.

The findings from Pound, et. al. (2017) indicate that teens are not comfortable with the

ways in which they are currently receiving their sexual education courses. The sample was found

to dislike the abstinence approach to education, believing it to be unrealistic. Thus, the authors

determined this method ineffective. Instead, adolescents desired unbiased education on abortion,

contraception, and options if pregnancy occurs.

ADOLESCENT SEXUAL EDUCATION 6

In the Pound, et. al. (2017) report, teens asserted a want to receive education from

educators knowledgeable of and comfortable with the material. In comparison, health

professionals were in agreement that a familiar educator, such as a parent, teacher, or doctor,

should teach the material. They suggested that the sexual-educators should receive training on

the topics of sexual health including contraception, pregnancy, and STIs. Healthcare

professionals also agreed that sustainable sexual education should be delivered in several

different settings including at school, at home, and in the clinical setting.

Manlove, Fish, & Moore (2015) quantitatively researched effective programs which

delivered sexual education to teens less than 18 years old. The authors searched the LINKS

database for evaluations of these types of programs and categorized the sample of 103

evaluations into 5 groups: abstinence-only or abstinence-based education, comprehensive sex-

education, clinic-based education, youth-development education, and parent-youth education.

The variables analyzed were the impact of each type of program of pregnancy, STI rates, sexual

activity, and use of contraception. After review, each program was identified as “found to work”,

“mixed findings”, and “not found to work”.

In the study, Manlove, Fish, & Moore (2015) found that 30% of abstinence-based, 50%

of comprehensive, and 60% of clinic-based programs were found to work in relation to one or

more of the variables. All 14 of the effective abstinence-based programs mentioned condom use,

however no such program was found to decrease the rate of STIs or pregnancy. One hundred

percent of comprehensive educational methods found to be effective showed to lower STI and

pregnancy rates, and increase contraceptive and condom use. The clinic-based education was

among the most successful, and proved to be very effective. Sixty percent of this type of

education increased condom use, and reduced STIs and pregnancies.

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In a study conducted by Yip, et. al. (2015), the authors sought to gain insight into

pediatric nurses’ knowledge, attitudes, and practices in regard to adolescent sexual health.

Through an anonymous survey, Yip et. al. asked 349 nurses in Hong Kong about their

experiences with providing adolescents with sexual health education. Three variables were

tested: knowledge of pediatric nurses on up-to-date statistics in regards to adolescent sexual

health, as well as knowledge of preventative measures to implement into practice; attitudes of

pediatric nurses regarding adolescents and sexual health; and practices of pediatric nurses when

dealing with adolescents, how they facilitate discussion and provide education about sexual

health.

Yip et. al. (2015) found that these nurses were knowledgeable on sexual health topics,

however, they rarely felt comfortable in discussions of sexual health with teens. They report that

only 23% of nurses reported that they regularly talked about sexual health with their patients. In

addition, only a small portion of the participant responded correctly to over half of the questions

about adolescent sexual health. This indicates a need for change.

Discussion & Implications

Through the literature review, the writer sought information on points relevant to the

PICOT question. She selected the Finer & Philbin (2013) study as it provided information on

adolescents’ sexual experience, use of contraception and occurrence rate of pregnancy. This

study offers a great background for the writer to determine why the rate of STIs and conception

remains a problem for teens, as it shows that a large portion of this group initiate sexual activity

by 16 years old.

A limitation exists, however, as the writer sought to gain specific information on the rate

of condom use in adolescents. The authors group all forms of birth control together in their
ADOLESCENT SEXUAL EDUCATION 8

report, which leaves no room to determine how often teens are using barrier methods. This

creates uncertainty when trying to figure out methods for STI prevention, as condoms are the

most reliable form of prophylaxis (Finer & Philbin, 2013).

In the study conducted by Finer & Philbin (2013), the age of sexual initiation was also

studied in relation to the rate of STI transmission. This information shows that a similar trend in

outcome occurs as with teen pregnancy. Per the study, the earlier the age of sexual initiation, the

higher the rate of STI contraception. With over half of the adolescent population beginning

sexual activity by 16, there is an obvious risk for STIs and pregnancy. As Finer & Philbin (2013)

and Vasilenko, Kugler, & Rice (2016) show the age of sexual initiation in teens and its

correlation to rate of STIs and pregnancy, a logical conclusion is to teach adolescents abstinence.

The report from Manlove, Fish, & Moore (2015) offers information on the failure of

abstinence only education. While some abstinence-based programs were found to increase safe

practice, they did little to achieve their desired outcome – abstinence in adolescents. The only

programs found to increase use of condoms were the ones that mention the practice in the

curriculum. In addition to this report, Vasilenko, Kugler, & Rice (2016) also claim abstinence-

based education to be ineffective, stating that they do not reduce the risk of STIs. It could be due

to teen attitudes toward this type of program, as Pound et. al. (2017) states that adolescents see

abstinence as unrealistic. Taking this into account, the studies indicate that comprehensive sex-

education is the most effective.

Pound, et. al. (2017) provide information on the best practice of SRE in schools in the

UK. They found that providing knowledge to adolescents about how to practice sex safely and

prevent STIs and pregnancy. This can be compared to the Manlove, Fish, & Moore (2015) report

that comprehensive programs were shown to be effective a good portion of the time in terms of
ADOLESCENT SEXUAL EDUCATION 9

positive outcomes, and a view of the best practice can be determined. Within the limitations of

these two studies, it can be determined that safe-sex education does more than abstinence to

reduce the risk of STIs and pregnancy in teens.

The research shows that sexual education should be delivered in different settings (Pound

et. al., 2017; Yip et. al., 2015). The Yip, et. al. (2015) study offers insight into nursing practice

when dealing with the issue of teen sexuality. There is a clear lack of education and comfort in

this are for pediatric nurses. This is an issue, as this population of nurses is most likely to work

with teens. Based on evidence that safe-sex education is superior to abstinence-only education,

strategies need to be implemented in order for nurses to improve their practice.

Training needs to be provided to nurses on how to facilitate discussion with clients about

sexual activity and promotion of safe sexual practices. It is evident that the education should

come from a professional in a non-judgmental manner, and teens will be more receptive to

limitation of risk-taking behavior.

Limitations & Conclusion

Several limitations existed for the writer of this integrative review. First, the writer has

minimal experience with literature review, as well as small knowledge of the topic of adolescent

sexuality. Second, only one database, PubMed, was sourced for references. Additionally, on said

database, possible references were limited to peer-reviewed studies published in English within

the timeframe of 2012-2016. Of the 1,000 articles generated, only a small portion was free of

charge. Finally, the writer was given a delimitation of only five studies. All of the factors could

lead to an incomplete review of the literature.

In conclusion, it is evident that teens are initiating sexual activity at an early age, which

increases the risk for unplanned pregnancy and STIs. This integrative review was meant to
ADOLESCENT SEXUAL EDUCATION 10

retrieve information on specific rates of these risks and determine how to best deliver education

to this population in order to reduce such rates. The findings indicate that teens are most

receptive to an open dialogue about safe sex, and prefer comprehensive education. Thus, the

answer to the PICOT question is that safe-sex education is more effective in preventing STIs and

pregnancy in adolescents. This information can be used to assert that nurses should facilitate

comprehensive education into their practices. Further research should be conducted to determine

how to best implement this strategy.

ADOLESCENT SEXUAL EDUCATION 11

References

Finer, L. & Philbin J. (2013) Sexual initiation, contraceptive use, and pregnancy among

young adolescents. Pediatrics. 131(5): 886–891. doi:10.1542/peds.2012-3495

Manlove, J., Fish, H., & Moore, K. A. (2015). Programs to improve adolescent sexual

and reproductive health in the US: a review of the evidence. Adolescent Health, Medicine

and Therapeutics, 6, 47–79. doi: 10.2147/AHMT.S48054

Pound, P., Denford, S., Shucksmith, J., Tanton, C., Johnson, A. M., Owen, J., . . . Campbell, R.

(2017). What is best practice in sex and relationship education? A synthesis of evidence,

including stakeholders’ views. BMJ Open, 7(5). doi:10.1136/bmjopen-2016-014791

Vasilenko, S., Kugler, K., & Rice, C. (2016). Timing of first sexual intercourse and

young adult health outcomes. The Journal of Adolescent Health, 59(3), 291–297. doi:

10.1016/j.jadohealth.2016.04.019

Yip, B., Sheng, X., Chan, V., Wong, L., Lee, S., Abraham, A. (2015). ‘Let’s talk about

sex’ – a knowledge, attitudes and practice study among pediatric nurses about teen sexual

health in Hong Kong. Journal of Clinical Nursing. 24(2): 2591-2600. doi:

10.1111/jocn.12869.